With the recent publicity concerning the physician assisted suicide of Brittany Maynard, maybe it’s time to take a look at euthanasia in more detail. I’m going to use this post to start off a short series on euthanasia.

The word “euthanasia” is supposed to derive from the Greek “euthanatos” (εὐθανασία) usually translated as “a gentle death” or “a good death.” As such, someone who dies painlessly from natural causes or artificial causes can have experienced euthanasia. But generally, we think of euthanasia as a process that is carried out by a human (or human agency.) Someone takes an overdose of a medication with the intent of committing suicide. Or, if a legal execution is carried out painlessly, it can be classed as euthanasia.

Brittany Maynard

Brittany Maynard

Suicide is somewhat different. In cases of suicide, the victim and no one else, is the actor and the method chosen can be without regard to whether there will be pain involved. The suicide carries out his demise totally by his own hand via whatever means available: shooting, a staged “accident,” poisoning, hanging or using other methods. So some suicides can be a form of euthanasia, depending on the setting and the means selected.

Euthanasia can also be subclassified as follows:

• Voluntary euthanasia – the person is mentally competent, informed of his outcomes and choices and desires that his life be ended humanely.

• Non-voluntary euthanasia – the person has not expressed the desire to die and is unable to make an informed choice (e.g. someone who is mentally incapable of understanding and making such a choice: an infant, someone who is mentally retarded, someone who is insane, etc.) In this instance, euthanasia is offered because the patient is terminally ill, may have unrelieved pain, may have a very poor quality of life, etc. An example might be an infant who is terminally ill, whose suffering is unable to be relieved whose parents give consent.

• Involuntary euthanasia – the person has made an informed choice to refuse assistance to die (e.g. a condemned criminal who opposes his sentence.) Involuntary euthanasia, other than lawfully performed by a government, is legal everywhere.

The above can be further subdivided into “active” and “passive” forms of euthanasia.

• Active euthanasia is considered the administration of some substance that acts to kill (e.g. a lethal injection.)

• Passive euthanasia is withholding something that could be necessary to support life in some patients. Examples would be not starting antibiotics for an infection in a terminally ill patient, not initiating IV fluids and nutrition in a dying patient unable to eat, etc.

Since we’re not talking about a gentle death from natural causes we need to look at how euthanasia can be carried out.

Technically, euthanasia can be performed by the patient himself, or the patient can be passive and someone else acts to end his life (either at his request, or otherwise.) The patient may act completely on his own, planning and executing his death. Or he may collaborate with someone else who aids him with his plan. In the first case, the patient might use some previously prescribed medications to end his life acting solely on his own. Or he might ask his spouse or a friend to provide some of his/her medications and use them for the same end. These are instances of voluntary euthanasia.

Of course, in the instance of capital punishment, the government will provide and administer the drugs without any action on the part of the condemned (involuntary euthanasia). Something similar could be done in a form of non-voluntary euthanasia.

Under the above definitions, Brittany’s suicide would be a voluntary euthanasia where others helped her to carry out her wishes. That subclass of euthanasia has come to be known as “assisted suicide (AS) or “physician-assisted suicide (PAS.)” I’d argue that, since the methods chosen for these types of suicide are painless, they’d be more appropriately called “assisted euthanasia” or “physician-assisted euthanasia” rather than suicide.

For the most part, AS and PAS are forms of voluntary euthanasia where the patient requests that someone else assists him to end his life. That is, the patient must rely on someone else to supply the means to his end. A physician, family member, pharmacist, etc. who provides medications that the patient can use to overdose. Or to supply him with some other means with which to commit suicide. In these instances, the patient still retains control and administers the medication or makes use of other means himself. That is, the process is both patient-directed and patient-controlled.

Brittany Maynard on her wedding day.

Brittany Maynard on her wedding day.

Looking back into the history of euthanasia, we can view the work of Dr. Jack Kevorkian a physician who was a pathologist. He was very interested in death and later in his career, advocated for euthanasia. He acted acted as a “death consultant.” He allegedly would advise a terminally ill patient about different methods of suicide. Then, if the patient wanted to proceed, Kevorkian would set up one of two machines that he constructed. One would administer a lethal injection of drugs intravenously when the patient pushed a button. The other would release carbon monoxide gas into a mask placed over the patient’s face, again when the patient pressed a button. In these circumstances, the patient took his own life with a degree of external assistance. So Brittany’s suicide was also assisted in that respect. She obtained the drug combination that she used from an Oregon physician.

Many people think that euthanasia has to be done with medications: sedatives, opioids, tranquilizers or other drugs. While that i.e. often the case, there are other methods of euthanasia that are available. As I mentioned above, Dr. Kevorkian made use of a lethal gas instead of a pharmaceutical.

Euthanasia/AS isn’t an option for most people in the world or in the US. It is prohibited in most places. That’s why Brittany had to leave San Francisco to move to Oregon. Oregon is one of the few states which has a “death with dignity” (or similarly titled) law that allows for a patient to be able to end his own life. Oregon, Montana, Vermont, Washington and New Mexico permit assisted suicides under certain circumstances. In no state is it legal for anyone, physician or other person, to directly administer euthanasia. The patient must do that himself.

Countries that permit euthanasia are: Luxembourg, the Netherlands and Belgium (here, the physician administers the euthanasia agent.). Assisted suicide (where the patient takes his own life) is legal in Switzerland, the Netherlands and Luxembourg.

Child euthanasia is legal in Belgium. In the Netherlands, it is technically illegal for children under 12 years old. However, those following the “Groningen Protocol” will not be prosecuted.

Most states and countries that allow either lawful euthanasia or assisted suicides have very strict guidelines concerning how they can be carried out.

Places that allow euthanasia or assisted suicide have rigid requirements that must be adhered to whether for euthanasia or AS/PAS. Some of these include the following (though the requirements may vary by location):

That the patient be terminally ill. That has usually come to mean that the patient is expected to have six months or less of life left. Though, realistically, it can be impossible to predict this. In Brittany’s case, she was initially told that she might live a few years. Later that estimate was drastically reduced. Yet she still outlived the expectations placed on her.

There may also be a phrase included in the law saying something like the patient must have “intractable suffering” from some disease. That often means cancer as the cause of the suffering , but there are also other diseases that would qualify. Severe heart disease, advanced pulmonary diseases and others are possibilities that might fulfill the “intractable suffering” requirement.

The patient may be required to undergo psychological testing to make sure that he is capable of understanding his choice. This also allows for the examiner to judge if the patient is suffering from some form of mental illness or depression that might influence him unduly.

Often the patient must make his request in writing, request assistance with suicide more than once, see at least two different physicians who both agree that this patient is one who is appropriate for assisted suicide.

This is a brief overview of a broad and controversial topic. In the remainder of the series, we’ll look at some other aspects of euthanasia/AS/PAS that need to be considered in a topic as important as this is.

This article, and the ones that follow, are meant to provoke a discussion, both here on AMERICAblog and elsewhere. A discussion that will allow people to express opinions and ideas on euthanasia and assisted suicide and, perhaps, lead to encouraging the public to take a look at euthanasia, AS and PAS in a different light. Possibly this might lead to legislative changes.

Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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